Background There are many reasons why concussion in children needs to be considered different from adults. The Zurich (2008) recommendations on the management of concussion in children are restricted to children less than to 10 years of age. It does not include recommendations for children aged 5–10 years. The aim of this study is to review the current literature on (1) concussion assessment at the sideline and during recovery stages, especially in the age group 5–15 years, and (2) the management of concussion in children and adolescents.
Methods A literature review using the MEDLINE database was undertaken. Articles were selected that included evaluation and/or management in children aged 5–15 years.
Results There are no sideline assessment tools validated for use in this age group. There are a number of different symptom scales that have been validated during different stages of the follow-up assessment in children. No single paediatric concussion assessment tool has been validated for use from sideline through to all stages of recovery. Reliability studies have been published on Balance Error Scoring System in children, but validity studies in this age group have not been published. The management of concussion includes withdrawal from play on the day and cognitive and physical rest. The priority of concussion management in children is to return to learn; while this is usually rapid, there are some children in whom a graduated return to school is required, which should include a number of accommodations.
Conclusions A young child is physically, cognitively and emotionally very different from adults, and requires the use of a different set of tools for the diagnosis, recovery-assessment and management of concussion. Age-specific, validated diagnostic tools are required, and management of concussion in children should focus attention on return to learn before considering return to play.
- Children's injuries
- Head injuries
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It is often stated that children are not just little adults. In the management of concussion, there are many reasons why a child needs to be considered different from adults, including (1) physiological development, (2) impact forces and protective abilities, (3) physical and cognitive recovery, (4) effects on school and learning and (5) potential for long-term sequelae from concussion. The young, immature, brain, with decreased myelination is developing rapidly during the early school-age years, and the young child's skull is relatively thin, with poorly developed cervical musculature supporting the preadolescent head.1–3 It has been suggested that the impact force required to produce concussion is greater in children than adults, and that the poorly developed cervical musculature, in combination with the increased head-to-neck ratio in children, results in greater injury to the child's brain, than the adult's, for the same impact force.4 ,5 In a study of biomechanics, using anatomical models and animal model research, Ommaya et al5 expand on theories initially proposed in the 1940s by Holbourn6 on the importance of angular acceleration in head injury. In a series of animal models, including a primate model, Ommaya et al5 demonstrated that larger brains were more vulnerable at lower levels of angular velocity and acceleration (as predicted by Holbourn), and higher levels of angular acceleration were required to cause similar injury to smaller brains. Extrapolating their animal model results in humans, they determined that approximately 4500 radians/s2 of rotational acceleration is required to produce concussion in an adult brain compared with approximately 10 000 radians/s2 for infants.
The role of brain development, neuronal plasticity and brain myelination in children may significantly impact the outcomes for concussion in children. Brain plasticity involves anatomical and chemical remodelling based on the person's age and environment. While brain plasticity promotes functional cerebral changes in skill acquisition (eg, remodelling sensorimotor function in learning to play a musical instrument), it also results in a degree of vulnerability in the setting of trauma.7 Furthermore, brain myelination has a typical developmental regional pattern, starting with sensorimotor areas of the brain in the earliest months and years, before extending to parietal, temporal and prefrontal regions later in childhood and adolescence.8 Therefore, the younger child with concussion will have reduced myelination in the prefrontal and temporal areas, which may alter the recovery time course and outcomes. The recovery from concussion in children generally occurs over a longer time period than in adults. This is evident in time for symptom resolution,9 as well as neurocognitive recovery.10 ,11 On an average, concussed high school athletes take twice as long to recover (10–14 days) than college and professional athletes (3–7 days),9 ,12 and preadolescent children may take even longer to recover. These effects may have significant impact on the child's ability to return to school because of the concussive neurocognitive deficits such as slowed information processing, difficulty forming new memory and inability to concentrate.
While the long-term effects of a single or multiple concussions are not yet known, it is apparent that a child exposed to a first concussion at a younger age will have a larger ‘window of opportunity’ for further concussive injuries during the formative years than a person who does not sustain a first concussion until college.2 It is considered that this larger window of time exposure to repeated concussion places the child at greater risk of long-term sequelae. Furthermore, the entity of rapid onset, postconcussive, malignant cerebral oedema is known to occur only in young children and adolescents, and does not occur in the adult population.13 ,14
Assessment of tools for concussion evaluation in children is complicated by definitions of concussion and mild traumatic brain injury (mTBI), age stratification of children and the tendency by many to treat children as merely small adults. The Consensus Statement on Concussion in Sport, from the 3rd International Conference on Concussion in Sport, held in Zurich 200815 suggested (based on expert opinion) that the Sport Concussion Assessment Tool 2 (SCAT2) is applicable to children as young as 10 years of age; however, the literature supporting this recommendation is limited in the extreme. This paper reviews the current literature on (1) concussion assessment at the sideline and during recovery stages, especially in the age group 5–15 years and (2) the management of concussion in children and adolescents.
The MEDLINE database was searched using search terms concussion, children, pediatric, child, mild traumatic brain injury and postconcussive symptoms. Reference lists from retrieved articles were searched for additional articles, and the authors’ own collections of articles were included in the search strategy.
Inclusion criteria included articles that were specifically on paediatric concussion, English language, original studies, cognitive assessment, physical assessment, balance assessment, symptom assessment and management of concussion. Exclusion criteria were those articles on moderate/severe head injury, review articles, adult patients only, full article not available and abstract only available. This study did not examine the following techniques: neuropsychological testing (computerised and formal), functional MRI, connectivity MRI, positron emission tomography and blood markers.
Tools for sideline assessment of concussion in children
Many and varied tests are available for the sideline assessment of concussion in adults, but none has been specifically developed for the sideline assessment of concussion in children. Some of the adult sideline tests that have been evaluated for use in children include the Standardized Assessment of Concussion (SAC),16–19 and SCAT2.20 ,21 However, none of these have been adequately evaluated for use on the sideline in children, and none has sufficient reliability and validity data to establish the tool as a reliable and valid sideline assessment tool in children.
Symptom evaluation remains as a key element of concussion assessment, and is very important in the diagnosis of concussion, monitoring recovery and return-to-play decision-making. The use of scales for detecting the presence of symptoms is common to most concussion assessment tools. The SCAT2 incorporated the modified adult symptom scale from the Post-Concussion Scale (PCS), but a paediatric version was not included in the SCAT2. Many symptom scales have been developed for use in adults, and a review of the psychometric properties of these scales for use in children by Gioia et al22 was published in 2009. A more recent review of symptom scales for use in mTBI in children has also been published23 (see Box 1). Some of these symptom scales have been tested in children to assist with the diagnosis of concussion,24 while others have been tested as markers of persistence of symptoms25–29 or to monitor the stages of recovery.30 None has been used and validated in children in each stage of concussion, from sideline through to recovery.
Some commonly used paediatric postconcussion symptom scales
Concussion Symptom Inventory (CSI)33
Tools for monitoring recovery of concussion in children
Sideline assessment tools and symptom scales useful for the diagnosis of concussion in children can also be of assistance in monitoring recovery from concussion, which will assist the practitioner in determining fitness for return to play. Tools that have potential use to monitor recovery from concussion in children include child- and parent-reported symptom scales25 ,26 ,28 ,29 and child assessments.17 ,26 ,30 ,34 However, there are no published data on the serial testing of concussed children from the sideline through the stages of recovery and ultimately return to sport.
It has been noted in adults that clinical depression can be misdiagnosed as persistent postconcussion symptoms.38 A similar study has not been performed in children, but highlights the difficulties that arise in differentiating concomitant psychiatric symptoms from postconcussive symptoms. Such symptom presentation may be exacerbated in the dysfunctional family, where the parent-reported symptoms may be less reliable or differ markedly from the child-reported symptoms.
The physical consequences of concussion include somatic symptoms (eg, headache, dizziness, photophobia and phonophobia), which are assessed in the symptom scales, and balance disturbance. While balance is included in the symptom scales, it can be objectively assessed in the clinic and on the sideline. Assessment of balance following concussion can be performed with the use of complex equipment in the laboratory39 or with minimal equipment at the sideline.19 ,40 The Balance Error Scoring System (BESS) is the most commonly used, and the simplest to employ, and was therefore included in the SCAT2 in a modified form. Validity results of the BESS used in concussion in young children have not been published, although reliability studies demonstrating the use of BESS in children aged 9–14 years have shown a significant learning effect with repeated exposure, and variability in results between the different leg stances.18 ,19
While simple reaction time is an integral element of many computerised cognitive assessments, it can be measured simply on the sideline or in the clinic, without the requirement for a computer, and does show promise as a tool for assessment of physical and cognitive function.41 The use of a weighted stick (or linear ruler) dropped by the examiner and caught by the athlete can be used to calculate the simple reaction time. A recent study42 on its use in a small cohort of concussed university and high school athletes demonstrated that the reaction time was sensitive in distinguishing between concussed and control athletes, with its sensitivity similar to other concussion assessment tools, but its utility in young children has not yet been demonstrated.
There have been very few studies evaluating the management of concussion, particularly in younger age groups. However, consensus agreement maintains that the keystone of concussion management in all age groups, including children and adolescents, is REST, both physical and cognitive.15 ,43 ,44 A recent study in high school-age and college-age athletes indicated that a period of cognitive and physical rest, regardless of whether it is observed immediately following a concussion or later in the course of recovery, resulted in decreased symptoms and improved performance on computerised neuropsychological testing.45
Physical rest should include restrictions of sport participation, training, physical education classes as well as leisure activities (bike riding, skateboarding, roller blading, etc).43 ,44 Restrictions on physical activity should be maintained until the child/adolescent is asymptomatic at rest.15 ,43 ,44 Once asymptomatic at rest, children/adolescents can progress through a medically supervised graduated exertion protocol.15 ,43 ,44 It is recommended that this return-to-play protocol be cautious and individualised in paediatric athletes,15 ,43 ,44 ,46 regardless of level of participation,15 as there is evidence that younger athletes take longer time to recover from concussion and have more significant neurocognitive effects from concussion.9 ,11 ,47 ,48 No paediatric athlete who has sustained a concussion should be allowed to return to play the same day.15 ,43 ,44 ,46
Cognitive rest includes limiting any activity requiring concentration and attention which exacerbates symptoms, including television, video/electronic games, texting, computer work and reading.15 ,43 ,44 Participation in these activities may increase concussion symptoms and prolong recovery,15 ,43 ,44 a concept known as ‘cognitive overexertion’.49 In paediatric athletes attending school, cognitive rest can be challenging. Currently, there are no clear guidelines to guide the return to school for youths who have sustained a concussion, although this is an area of increasing interest. Given that children and adolescents spend a significant amount of their time in the classroom, and that school attendance is vital for them to learn and socialise, full return to school should be a priority following a concussion. Return to learn should precede return to play.
The cognitive effects of concussion include decreased learning and memory, decreased attention, slowed processing speed and decreased reaction time.17 ,50 ,51 These effects can negatively impact on a student's ability to participate, learn and perform in school.27 ,50–52 Anxiety and nervousness, which may be a direct result of a concussion, but may also be secondary to a student's concern about falling behind in school, may further impair cognitive function.49 ,53 A student who is concerned about keeping up with his/her studies may not comply with advice regarding cognitive rest and may exacerbate symptoms by persisting with school attendance and completing assignments.
The transition back to school following a concussion may need to be gradual, as symptoms allow. A stepwise approach of increasing cognitive activity, similar to the stepwise exertion protocol for return to play, will allow students to return to the academic setting without exacerbating their symptoms.49 ,53 Cognitive rest may initially require a temporary absence from school to allow symptoms to abate.43 ,44 Once symptoms have decreased and a patient is able to do more cognitive tasks at home without exacerbation of symptoms, a gradual return to school is advocated, which may mean attending for only half a day or for only certain classes.43 ,44 ,49 ,53 A concussed student does not have to have total resolution of their symptoms prior to resuming school attendance. However, specific accommodations, or modifications, to a patient's academic schedule may be required to allow the patient to return to school without exacerbating their symptoms during recovery. Examples of such accommodations and their relationship to clinical symptoms and school/learning effects are outlined in table 1.
The development of the child's brain and the associated physical growth of the child, especially between the ages 5 and 15 years, necessitate a specialised approach to concussion management in this age group. The majority of ‘youth’ studies in concussion have been in high school and college students in North America, where the average age of the cohort is greater than 15 years. Generalisation of those results cannot be used to apply to the younger age group, and therefore specialised tests need to be developed for the paediatric group. Such tests need to allow for language development, reading development, cognitive development and physical development. The development of cognitive maturity with age improves steadily between ages 5 and 15 years, and approaches a plateau at 15 years.52 Thus, concussion assessment in children aged 5–15 years must accommodate these developmental changes. Symptom scales must include language that is understood by young children and symptoms that are familiar to children. The addition of parent or teacher reports of symptoms can be integrated into recovery as well as return-to-learn and return-to-play decision-making. Cognitive tests must be developmentally appropriate, and demonstrate validated change to concussion and recovery. Physical tasks must be reliably performed by normal children, and demonstrate impaired response in concussion, that corrects with recovery. The full complement of tests must fall within the concentration span of the normal and the concussed child, so validating isolated elements of an overall test separately may not be representative of the true clinical environment. For example, testing the BESS in isolation may validate the BESS as an instrument for use in children; but, if it is incorporated in a child version of the SCAT2, then it must be validated when used with symptom scoring and cognitive assessment, to control for the increased requirement for concentration and attention by the concussed child.
Unlike the adult concussion protocols that assume a primary endpoint of return to play, the child protocol must assume a primary endpoint of return to school. Managing the negative effects of concussion that impact on the child's ability to learn in school requires a cooperative approach between child, parents, teachers and medical staff. Return to learn should follow a stepwise increase in cognitive activities. Initially, a temporary absence from school after a concussion may be necessary to allow symptoms to improve.43 ,44 Once symptoms have decreased and a patient is able to perform more cognitive tasks at home without exacerbation of symptoms, a gradual return to school is advocated, which may mean attending for only half a day or for only certain classes.43 ,44 ,49 ,53 Specific accommodations, or modifications, to the academic schedule may be required to allow return to school without exacerbating a student's symptoms during concussion recovery.44 ,48 Accommodations should be individualised, depending on the symptoms or difficulties that the youth is experiencing.49 ,53
As with many aspects of medicine, transitioning students recovering from a concussion back to school is best achieved with a team approach.49 ,53 Multidisciplinary teams may include the student, the family/guardians/caregivers, the coach and trainers, the physician, the teachers, the school principal and other school personnel as available (counsellors, nurses, athletic trainers and neuropsychologists). Communication among team members, as well as education of all members, is vital to ensure that all team members are aware of the student's progress and the accommodations necessary to facilitate the student's recovery.
The young child is physically, cognitively and emotionally very different from adults, and requires the use of a different set of tools for the diagnosis, recovery-assessment and management of concussion. Age-specific, validated diagnostic tools are required, and management of concussion in children should focus attention on return to learn before considering return to play.
Contributors GAD and LKP contributed equally to the study design, interpretation of results and drafting the manuscript and decided to submit the manuscript.
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.
▸ References to this paper are available online at http://bjsm.bmj.com
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